Do you use nitroglycerin (nitro) for right-sided ST-elevation myocardial infarction (STEMI)?

From the Guidelines

Nitroglycerin should not be used in patients with right-sided ST-segment myocardial infarction (STEMI) who have suspected right ventricular infarction or hypotension, as it can worsen hemodynamics and reduce preload, potentially leading to profound hypotension. The use of nitroglycerin in right-sided STEMI requires careful consideration, as right ventricular function depends heavily on adequate preload. According to the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1, nitrates are contraindicated in patients with initial systolic blood pressure less than 90 mm Hg or 30 mm Hg below baseline and in patients with right ventricular infarction.

Some key points to consider when deciding whether to use nitroglycerin in right-sided STEMI include:

• Assessing hemodynamic status before administering nitroglycerin
• Avoiding nitroglycerin in patients with suspected right ventricular infarction or hypotension
• Considering alternative treatments, such as fluid administration to maintain right ventricular preload, antiplatelet therapy, anticoagulation, and reperfusion therapy
• Monitoring blood pressure closely if nitroglycerin is used in hypertensive patients with right-sided STEMI. The ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction also support the cautious use of nitrates in patients with right ventricular infarction, citing the risk of hypotension and decreased preload 1.

In general, the management of right-sided STEMI should prioritize maintaining right ventricular preload and ensuring adequate hemodynamics, rather than relying solely on nitroglycerin for treatment. The most recent and highest quality study, the 2010 American Heart Association guidelines 1, provides the best guidance for managing right-sided STEMI and highlights the importance of careful consideration when using nitroglycerin in these patients.

From the FDA Drug Label

CONTRAINDICATIONS Nitroglycerin sublingual tablets are contraindicated in patients who are allergic to it. Sublingual nitroglycerin therapy is contraindicated in patients with early myocardial infarction, severe anemia, increased intracranial pressure, and those with a known hypersensitivity to nitroglycerin. WARNINGS The benefits of sublingual nitroglycerin in patients with acute myocardial infarction or congestive heart failure have not been established. If one elects to use nitroglycerin in these conditions, careful clinical or hemodynamic monitoring must be used because of the possibility of hypotension and tachycardia.

Nitroglycerin use in right side STMI is not directly addressed in the provided drug labels. However, it is mentioned that sublingual nitroglycerin therapy is contraindicated in patients with early myocardial infarction 2. Additionally, the benefits of sublingual nitroglycerin in patients with acute myocardial infarction have not been established 2.

• The labels do not provide information on the specific use of nitroglycerin in right side STMI.
• Caution is advised when considering the use of nitroglycerin in patients with myocardial infarction, due to the possibility of hypotension and tachycardia 2.

From the Research

Use of Nitroglycerin in STEMI

• The use of nitroglycerin in patients with ST-segment elevation myocardial infarction (STEMI) is a topic of interest, particularly in those with right ventricular infarction or inferior STEMI 3.
• A study published in 2016 found that nitroglycerin administration to patients with inferior STEMI is not associated with a higher rate of hypotension compared to patients with STEMI in other territories 3.
• The American Heart Association recommends the use of nitroglycerin in patients with STEMI, but cautions against its use in patients with right ventricular infarction or those who are hypotensive 4.
• In terms of specific guidelines for the use of nitroglycerin with right side STEMI, there is limited evidence available, but it is generally recommended to use caution and monitor patients closely for signs of hypotension or other adverse effects 3, 4.

Management of STEMI

• The management of STEMI typically involves immediate reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis 5, 4.
• The choice of reperfusion therapy depends on various factors, including the time from symptom onset to presentation, the location of the infarct, and the availability of PCI facilities 5, 4.
• In patients who receive fibrinolysis, rescue PCI may be considered if there is evidence of failed reperfusion or if the patient develops signs of ischemia or infarction 6.
• The use of antithrombotic therapy, including dual antiplatelet therapy and anticoagulation, is also an important aspect of STEMI management 5, 4.